Published 4:00 am, Saturday, March 31, 2007

President Bush's $15 billion plan to fight AIDS globally is seriously hampered by restrictions imposed by Congress and the administration, a panel of medical experts said Friday.

The country's most prestigious medical advisory panel, the Institute of Medicine, was asked by Congress to assess the five-year plan at its midpoint. The 13 members of the panel praised the initiative, saying it has "demonstrated what many doubted could be done."

But the initiative needs to move from an emergency response to a long-term plan, the panel said, and its members listed three restrictions that they felt were the most hindering: a requirement to spend one-third of funds on teaching chastity and fidelity; the need for Food and Drug Administration approval of AIDS drugs; and the prohibition on spending taxpayer money to give drug addicts clean needles.

Dr. Mark Dybul, the global AIDS coordinator who oversees the President's Emergency Plan for AIDS Relief, known as PEPFAR, said he welcomed the report as "quite an endorsement of our program," but he disagreed with the panelists on some aspects.

The $15 billion that Bush promised in his State of the Union address in 2003 is far more than any other country has spent fighting AIDS outside its borders and far more than any previous administration spent. Although the ambitious plan has not yet helped as many people as its original goals envisioned, the panel endorsed financing it beyond its 2009 expiration date.

At its halfway point, the program is not halfway toward meeting its goals, which included treatment for 2 million people, caring for 10 million and preventing 7 million new cases of AIDS by 2010. As of September, the program was underwriting treatment for 822,000 people.

"Overall, PEPFAR is doing quite well, has made a good start, but it needs to transition from emergency mode to a sustainable effort," said Dr. Jaime Sepulveda, director of National Institutes of Health in Mexico and the panel chairman. Sepulveda is also a visiting professor of global health sciences at

UCSF.

With its limited funds, the program has to focus much more on prevention than treatment. "Otherwise," Sepulveda said, "the epidemic will never end."

He added that the plan needed more freedom to tailor its responses to each of its 15 "focus countries," Guyana, Haiti, Vietnam and 12 African countries.

Congress requires that 55 percent of the budget be spent on treatment, 15 percent on care for the dying and 10 percent on children and orphans. Of the 20 percent left for prevention, a third must be spent on promoting abstinence until marriage.

The law against using taxpayer dollars for needle swaps predates PEPFAR.

Critics have said that under pressure from those directives and conservative Christians, the plan tends to give condoms to prostitutes and truckers but only abstinence advice to young people; offers counseling rather than clean needles to drug addicts; and does too little for women and girls likely to be infected by rape or by their husbands.

The rules forbid using the money to distribute condoms in schools, the panel said, and "returning to abstinence" is a primary message for youths having sex.

"Given the reported early average age of sexual debut (and sometimes marriage) in many countries, PEPFAR may wish to re-examine its exclusive AB focus for younger adolescents," the report said. (AB is short for "abstinence/be faithful.")

Dybul has often rejected such criticisms, saying that young children should be given abstinence messages and that his agency can still tailor its approach, because the mandates apply to overall expenditures.

The rules

The Institute of Medicine criticized these restrictions in the anti-AIDS plan:

-- The requirement that 33 percent of all funds for prevention be spent teaching chastity and fidelity, even in countries where most cases are spread by drug injection.

-- The need for separate Food and Drug Administration approval of AIDS drugs that already have been approved by the World Health Organization.

-- Laws forbidding the use of taxpayer funds to give clean needles to drug addicts.